Provider Demographics
NPI:1730292970
Name:OLD PORT PHARMACY, INC
Entity Type:Organization
Organization Name:OLD PORT PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:CHACE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-240-1082
Mailing Address - Street 1:195 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4003
Mailing Address - Country:US
Mailing Address - Phone:207-772-2164
Mailing Address - Fax:207-353-0638
Practice Address - Street 1:195 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4003
Practice Address - Country:US
Practice Address - Phone:207-772-2164
Practice Address - Fax:207-353-0638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPH500012743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy